Raw X12 — CIN XG58434W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1920*|*00501*648850497*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1920*850497*X*005010X279A1~ST*270*0497*005010X279A1~BHT*0022*13*202608131920000001*20260813*1920~HL*1**20*1~NM1*PR*2*NYSDOH*****PI*EMEDNY~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~PRV*PE*PXC*251B00000X~HL*3*2*22*0~TRN*1*202608131920000001*00000000ND~NM1*IL*1******MI*XG58434W~EQ*30~DTP*291*D8*20260814~SE*13*0497~GE*1*850497~IEA*1*648850497~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1520*^*00501*540275830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152046*540275830*X*005010X279A1~ST*271*540275830*005010X279A1~BHT*0022*11*202608131920000001*20260813*152046~HL*1**20*1~NM1*PR*2*NYSDOH*****FI*141797357~PER*IC*EMEDNY PROVIDER SERVICES*TE*8003439000*UR*www.emedny.org~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~HL*3*2*22*0~TRN*2*202608131920000001*00000000ND~NM1*IL*1*MENANUNEZ*JUSTO*P***MI*XG58434W~N3*1521 SHERIDAN AVE             C61~N4*BRONX*NY*10457~DMG*D8*19590809*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*SENIOR WHOLE HEALTH MAP*****PI*YH~N3*15 METROTECH CTR~N4*BROOKLYN*NY*112013818~PER*IC*PROVIDER SERVICES*TE*8773530185~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*R*IND*30~REF*6P*H5992~LS*2120~NM1*P4*2*SENIOR WHOLE HEALTH OF NEW YORK*****PI*H5992~N3*200 SOUTH PEARL STREET~N4*ALBANY*NY*12202~PER*IC*PROVIDER SERVICES*TE*8662111777~LE*2120~EB*R*IND*30~REF*18*9T46TM7WU30~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*40*540275830~GE*1*540275830~IEA*1*540275830~